=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942576681
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VANJA VARENIKA M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2012
-----------------------------------------------------
Last Update Date | 04/02/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1510 COTNER AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-218-8007
-----------------------------------------------------
Fax | 585-218-8099
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1510 COTNER AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90025-3303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-218-8007
-----------------------------------------------------
Fax | 585-218-8099
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | A128939
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------